术侧肺辅助小潮气量IPPV对周围型肺癌开胸患者氧合及炎性因子的影响

发布时间：2018-02-16 19:22

  本文关键词： 单肺通气 开胸手术 小潮气量通气 IPPV 炎性反应　出处：《河北医科大学》2014年硕士论文　论文类型：学位论文

【摘要】：目的：本研究拟评价单肺通气时术侧肺辅助小潮气量IPPV对周围型肺癌开胸患者氧合和炎性因子及术后恢复的影响。 方法：随机选取行周围型肺癌切除术患者20例，年龄45~65岁，性别不限，体重49~80Kg。患者均为ASAⅠ~Ⅱ级，术前患者未经过放疗、化疗等治疗，并且无内分泌及免疫系统疾病，无激素及免疫药物应用史，无严重心肺肝肾功能障碍。选取同一组医生手术的肺癌患者。将患者按照完全随机对照原则分为IPPV组（A组）和对照组（B组）。所有患者入室后均建立上肢静脉通路，随后在局麻下桡动脉穿刺置管，术中连续监测有创动脉压。术前30min静脉注射阿托品0.5mg，咪达唑仑0.05mg/kg。用IntelliVue MP50多功能监护仪监测患者的心电图（ECG），脉搏氧饱和度（SpO2），呼气末二氧化碳分压（PETCO2），在全麻诱导结束后颈内静脉置管监测中心静脉压（CVP）。麻醉诱导：所有患者均采用芬太尼、依托咪酯、顺阿曲库胺诱导，其剂量为芬太尼2～4μg/kg,依托咪酯0.2～0.3mg/kg，顺式阿曲库胺0.3mg/kg，3min后插入双腔支气管导管，然后用纤维支气管镜定位维持双腔管的正常位置，侧卧位后再次用纤维支气管镜定位，以确保导管位置良好。两组通气均采用Datex-Ohmeda7100麻醉机控制呼吸，双肺通气时潮气量为8~10ml/kg，呼吸频率为12次/分，吸呼比为1:2，单肺通气时潮气量为6~8ml/kg，呼吸频率为15~17次/分，吸呼比为1:2，，根据呼气末二氧化碳分压（正常值为35~45mmHg）调整呼吸参数；同时监测患者的气道峰压(Ppeak)，气道平台压（Pplat），使气道压低于30cmH2O。麻醉维持采用瑞芬太尼和七氟醚静吸复合麻醉，吸入七氟烷（1～3%），微量泵泵注瑞芬太尼0.5～1μg/kg/min。术中使患者的BIS值维持于40～60之间。间断静脉注射顺式阿曲库胺0.05mg/kg维持肌肉松弛，术中采用肌松监测仪监测肌松。两组患者单肺通气新鲜气体流量都给予1L/min。在单肺通气期间，对照组术侧肺的支气管导管直接开口于空气处于自然萎陷状态，试验组的术侧肺支气管导管接Datex-Ohameda7100呼吸机，新鲜气体流量为1L/min。呼吸参数设定：潮气量为1.2ml/kg，频率为15次/分,吸呼比为1:2。常规补液，输注15ml/kg/h乳酸钠林氏液和羟乙基淀粉氯化钠130/0.4注射液，晶胶比2：1，以维持血流动力学平稳，通过调整麻醉深度或使用药物使平均动脉压（MAP）和心率（HR）的变化幅度不超过基础值的20%。在麻醉前自主呼吸空气时（t0），肺叶切除后（t1），单肺通气结束时（t2），分别采集动脉血，用Cabs b123型号血气分析仪测定并记录血气分析pH值、动脉血氧分压（PaO2）、动脉二氧化碳分压（PaCO2）、血乳酸值（Lac）、BE值。同时记录患者在上述时间点的心率（HR）、脉搏血氧饱和度（SpO2）、平均动脉压（MAP）、中心静脉压（CVP）。 记录单肺通气的时间、手术时间、补液量、尿量、出血量、输血量。分别于插管即刻（T0）、手术结束即刻(T1)、术后24小时（T2）、术后48小时（T3）时，抽取中心静脉血4ml，测定血清IL-8、IL-10、TNF-α的水平。 术后随访：患者胸腔引流时间、引流量、拔管时间、抗生素使用时间、住院时间、费用、是否转ICU、生命体征、体温变化。 结果： (1)一般情况：两组患者年龄、体重指数、性别构成比、单肺通气时间、术时间、补液量、尿量、出血量，组间比较差异无统计学意义（P＞0.05）两组患者术中均未输血，血红蛋白的量在正常范围。 (2)检测指标 ①组间比较，T0时两组患者血浆中IL-8、IL-10、TNF-α的水平差异没有统计学意义。（P＞0.05） ②组间比较，TI、T2、T3时IPPV组和对照组相比两组患者的IL-8、IL-10、TNF-α的水平差异没有统计学意义（P＞0.05）。 ③A组患者血浆中的IL-8、IL-10、TNF-α的水平在T0、T1、T2、T3四个时间点比较差异有统计学意义（P＜0.05），IL-8的水平在T1点比T0点明显提高，在T2点开始降低，并且在T2、T3的水平明显低于T0。IL-10的水平在T1点比T0点明显提高，在T2点开始降低，并且在T2、T3的水平明显低于T0。TNF-α的水平并没有明显的变化趋势。 ④B组患者血浆中的IL-8、IL-10、TNF-α的水平在T0、T1、T2、T3四个时间点比较差异有统计学意义（P＜0.05），IL-8的水平在T1点比T0点明显提高，在T2点开始降低，并且在T2，T3的水平明显低于T0。IL-10的水平在T1点比T0点明显提高，在T2点开始降低，并且在T2、T3的水平明显低于T0。TNF-α的水平并没有明显的变化趋势。 ⑤两组患者体温、引流时间、住院时间、住院费用、心率、血氧饱和度，组间比较差异无统计学意义（P＞0.05），引流量和抗生素使用时间组间比较差异有统计学意义（P＜0.05）。 ⑥两组患者在t0、t1、t2三个时间点的动脉血气分析pH、PaCO2、Lac、BE值，通过比较差异均没有统计学意义（P＞0.05）但是PaO2通过比较在t1时间点差异有统计学意义（P0.05）。 结论：对周围型肺癌需行开胸手术的患者，在单肺通气期间对周围型肺癌患者非通气侧肺辅助1.2ml/kg的小潮气量IPPV既不影响术者操作又能提高氧分压，而且对患者术后恢复有一定的改善作用，但是对炎性因子没有影响。
[Abstract]:Objective: this research is to evaluate the effect of single lung ventilation with low tidal volume IPPV side lung assist for peripheral lung cancer patients with thoracic oxygenation and inflammatory factors and postoperative recovery.
Methods: 20 cases randomly selected patients undergoing resection for peripheral lung cancer, aged 45~65 years old, male or female, weight 49~80Kg. patients were ASA grade I-II, preoperative patients without radiotherapy, chemotherapy, and endocrine and immune system diseases, no hormones and immunosuppressive drugs should be used in history, no serious heart liver and kidney dysfunction. The same group of doctors surgery in patients with lung cancer. The patients were randomly divided into the control principle of IPPV group (A group) and control group (B group) were established. Upper extremity venous access in all patients after admission, followed by the radial artery puncture under local anesthesia, intraoperative continuous monitoring of arterial blood pressure. Preoperative 30min intravenous injection of atropine 0.5mg, midazolam 0.05mg/kg. with ECG IntelliVue MP50 multi-function monitor to monitor patients (ECG), pulse oxygen saturation (SpO2), end tidal carbon dioxide partial pressure (PETCO2), after induction of general anesthesia in internal jugular vein indwelling Tube monitoring central venous pressure (CVP). The induction of anesthesia: all patients were treated with fentanyl, etomidate, cisatracurium induced, the dose of fentanyl 2~4 g/kg, etomidate 0.2 ~ 0.3mg/kg, cisatracurium 0.3mg/kg, 3min after insertion of double lumen tube, then by bronchofibroscope location maintenance double lumen tube in normal position, lateral position again with bronchofibroscope location, to ensure good ventilation catheter position. The two group were treated with Datex-Ohmeda7100 anesthesia machine control breathing, double lung ventilation with a tidal volume of 8~10ml/kg, respiratory rate was 12 beats per minute, respiratory ratio is 1:2, during one lung ventilation tidal volume is 6~8ml/kg. The respiratory rate is 15~17 / min, suction call ratio was 1:2, according to the PetCO2 (normal 35~45mmHg) to adjust the respiratory parameters; at the same time, peak airway pressure (Ppeak) monitoring patients, airway pressure (Pplat) platform, the airway pressure is lower than 30 CmH2O. maintain anesthesia with remifentanil and sevoflurane combined anesthesia, inhalation of seven halothane (1 ~ 3%), micro pump infusion of remifentanil in 0.5 ~ 1 g/kg/min. of patients BIS value maintained at 40~60. Intermittent intravenous injection of cisatracurium 0.05mg/kg to maintain muscle relaxation, intraoperative use of muscle relaxation monitoring muscle relaxation. Single lung ventilation in patients of two groups were given 1L/min. fresh gas flow during one lung ventilation, control group lung bronchial catheter directly opening in the air in the natural state of collapse, the operative side bronchial catheter. Datex-Ohameda7100 ventilator test group, fresh gas flow was set 1L/min. respiratory parameters: tidal volume is 1.2ml/kg. The frequency of 15 beats per minute, respiratory ratio of 1:2. conventional fluid infusion of 15ml/kg/h, sodium lactate and sodium chloride hydroxyethyl starch solution by 130/0.4 injection, 2:1 crystal glue to maintain hemodynamics Stable, by adjusting the depth of anesthesia or the use of drugs to mean arterial pressure (MAP) and heart rate (HR) change rate does not exceed the value of the 20%. based autonomous breathing air before anesthesia (T0) when, after pulmonary resection (T1), at the end of one lung ventilation (T2), arterial blood were collected by Cabs type B123 blood gas analyzer was used to measure and record the blood gas analysis pH value, arterial oxygen pressure (PaO2), arterial partial pressure of carbon dioxide (PaCO2), blood lactate (Lac), BE values were recorded at the same time. The heart rate (HR), pulse oxygen saturation (SpO2), mean arterial pressure (MAP), central venous pressure (CVP).
The time of single lung ventilation, operation time, fluid volume, urine volume, bleeding volume and blood transfusion volume were recorded. At the time of immediate intubation (T0), immediately after operation (T1), 24 hours after operation (T2), and 48 hours after operation (T3), the central venous blood 4ml was drawn, and the levels of serum IL-8, IL-10 and TNF- alpha were measured.
Postoperative follow-up: thoracic drainage time, flow rate, extubation time, antibiotic use time, hospitalization time, cost, ICU, life sign, temperature change.
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